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Journals of Gerontology: MEDICAL SCIENCES
Cite journal as: J Gerontol A Biol Sci Med Sci. 2012 November;67(11):1272–1277
doi:10.1093/gerona/gls097
© The Author 2012. Published by Oxford University Press on behalf of The Gerontological Society of America.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
Advance Access published on March 27, 2012
1272
Journal of Gerontology: MEDICAL SCIENCES © The Author 2012. Published by Oxford University Press on behalf of The Gerontological Society of America.
Cite journal as: J Gerontol A Biol Sci Med Sci All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
doi:10.1093/gerona/gls097
1
HIP fractures (HF s ) represent a major challenge for phy-
sicians as well as society as a whole, given the high
frequency of this condition, the excess of mortality rate
within 1 year ( 1 ) , and the high rate of disability in the survi-
vors ( 2 ). Data suggest that negative outcomes occur mainly
in the frail older people , who have functional limitations
and limited physiological reserves with a reduced capacity to
return to their functional independence and autonomy prior
to HF ( 3 , 4 ). For these reasons, innovative care models have
been developed and implemented to minimize in-hospital
complications, streamline hospital care and provide early
discharge with the main objectives of improving functional
and clinical outcomes, and reducing direct and indirect
health care costs ( 5 ).
The timing of surgery is an important marker of a pa-
tient ’ s progress following a HF . It is now well established
that a delay to surgery greater than 24 – 72 hours from
admission is associated with an increased risk of complica-
tions and death irrespective of age and medical comorbidity
( 6 – 8 ). Therefore , guidelines recommend that surgery should
be performed on the day of, or the day after, admission
( 9 , 10 ) and that it is necessary to maximize the proportion of
medically fi t patients receiving early surgery. Because the
level of functional impairment affects the recovery of older
people with HF, we hypothesized that the timing of the
operation is more important for frail older people than for
older people without functional limitations before fracture.
The aim of this study was to examine the relationship between
Older People With Hip Fracture and IADL Disability
Require Earlier Surgery
Giulio Pioli , 1 Fulvio Lauretani , 2 Maria Luisa Davoli , 1 Emilio Martini , 3 Carlo Frondini , 3
Francesca Pellicciotti , 1 Anna Zagatti , 4 Antonio Giordano , 2 Ilaria Pedriali , 4 Anna Nardelli , 2
Amedeo Zurlo , 4 Alberto Ferrari , 1 and Maria Lia Lunardelli 3
1 Geriatric Unit, Department of Neuromotor Physiology, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy .
2 Geriatric Unit, Geriatric-Rehabilitation Department, University Hospital of Parma, Parma, Italy .
3 Orthogeriatric Unit, Department of Internal Medicine, Ageing and Nephrology, University Hospital Policlinico S. Orsola Malpighi,
Bologna, Italy .
4 Orthogeriatric Unit, S. Anna Hospital, Ferrara, Italy .
Address correspondence to Giulio Pioli, MD, PhD, Geriatric Unit, ASMN Hospital, Via Risorgimento 70, 42100 Reggio Emilia, Italy.
Email: giulio.pioli@asmn.re.it
Background. Hip fractures represent a major challenge for physicians as well as society as a whole. Both poor func-
tional status and delay to surgery are well known risk factors for negative outcomes. We hypothesized that the timing of
the operation is more important for frail older people than older people without functional limitations before fracture.
Methods. We performed a prospective multicenter cohort study on 806 consecutive patients, 75 years of age or older,
admitted with a fragility hip fracture to three hospitals in the Emilia-Romagna Region (Italy). All three hospitals had a
comanaged care model, and the patients were under the shared responsibility of an orthopedic surgeon and a geriatrician.
Results. Functional status assessed as instrumental activities of daily living was an important predictor of survival
after 1 year from fracture. After adjusting for confounders, the hazard ratios per 1 point score of increase from 0 to 8 was
1.30 (95% confi dence interval 1.19 – 1.42, p = .000). Time to surgery increased 1-year mortality in patients with a low
instrumental activities of daily living score (hazard ratios per day of surgical delay 1.14, 95% confi dence interval 1.06 –
1.22, p < .001) and intermediate instrumental activities of daily living score (hazard ratios 1.21, 95% confi dence interval
1.09 – 1.34, p < .001) but was an insignifi cant risk factor in functionally independent patients (hazard ratios 1.05 95%
confi dence interval 0.79 – 1.41, p = .706).
Conclusions. Surgery delay is an independent factor for mortality in older patients after hip fracture but only for the
frail older people with prefracture functional impairment. If our results are confi rmed, a more intensive approach should
be adopted for older people with hip fractures who have disabilities.
Key Words: Hip fracture — Mortality — Functional status — Frail elderly — Surgery delay .
Received October 16 , 2011 ; Accepted February 25 , 2012
Decision Editor: Luigi Ferrucci, MD, PhD
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HIP FRACTURE IN FRAIL OLDER PEOPLE 1273
Journal of Gerontology: MEDICAL SCIENCES © The Author 2012. Published by Oxford University Press on behalf of The Gerontological Society of America.
Cite journal as: J Gerontol A Biol Sci Med Sci All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
doi:10.1093/gerona/gls097
1
HIP fractures (HF s ) represent a major challenge for phy-
sicians as well as society as a whole, given the high
frequency of this condition, the excess of mortality rate
within 1 year ( 1 ) , and the high rate of disability in the survi-
vors ( 2 ). Data suggest that negative outcomes occur mainly
in the frail older people , who have functional limitations
and limited physiological reserves with a reduced capacity to
return to their functional independence and autonomy prior
to HF ( 3 , 4 ). For these reasons, innovative care models have
been developed and implemented to minimize in-hospital
complications, streamline hospital care and provide early
discharge with the main objectives of improving functional
and clinical outcomes, and reducing direct and indirect
health care costs ( 5 ).
The timing of surgery is an important marker of a pa-
tient ’ s progress following a HF . It is now well established
that a delay to surgery greater than 24 – 72 hours from
admission is associated with an increased risk of complica-
tions and death irrespective of age and medical comorbidity
( 6 – 8 ). Therefore , guidelines recommend that surgery should
be performed on the day of, or the day after, admission
( 9 , 10 ) and that it is necessary to maximize the proportion of
medically fi t patients receiving early surgery. Because the
level of functional impairment affects the recovery of older
people with HF, we hypothesized that the timing of the
operation is more important for frail older people than for
older people without functional limitations before fracture.
The aim of this study was to examine the relationship between
Older People With Hip Fracture and IADL Disability
Require Earlier Surgery
Giulio Pioli , 1 Fulvio Lauretani , 2 Maria Luisa Davoli , 1 Emilio Martini , 3 Carlo Frondini , 3
Francesca Pellicciotti , 1 Anna Zagatti , 4 Antonio Giordano , 2 Ilaria Pedriali , 4 Anna Nardelli , 2
Amedeo Zurlo , 4 Alberto Ferrari , 1 and Maria Lia Lunardelli 3
1 Geriatric Unit, Department of Neuromotor Physiology, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy .
2 Geriatric Unit, Geriatric-Rehabilitation Department, University Hospital of Parma, Parma, Italy .
3 Orthogeriatric Unit, Department of Internal Medicine, Ageing and Nephrology, University Hospital Policlinico S. Orsola Malpighi,
Bologna, Italy .
4 Orthogeriatric Unit, S. Anna Hospital, Ferrara, Italy .
Address correspondence to Giulio Pioli, MD, PhD, Geriatric Unit, ASMN Hospital, Via Risorgimento 70, 42100 Reggio Emilia, Italy.
Email: giulio.pioli@asmn.re.it
Background. Hip fractures represent a major challenge for physicians as well as society as a whole. Both poor func-
tional status and delay to surgery are well known risk factors for negative outcomes. We hypothesized that the timing of
the operation is more important for frail older people than older people without functional limitations before fracture.
Methods. We performed a prospective multicenter cohort study on 806 consecutive patients, 75 years of age or older,
admitted with a fragility hip fracture to three hospitals in the Emilia-Romagna Region (Italy). All three hospitals had a
comanaged care model, and the patients were under the shared responsibility of an orthopedic surgeon and a geriatrician.
Results. Functional status assessed as instrumental activities of daily living was an important predictor of survival
after 1 year from fracture. After adjusting for confounders, the hazard ratios per 1 point score of increase from 0 to 8 was
1.30 (95% confi dence interval 1.19 – 1.42, p = .000). Time to surgery increased 1-year mortality in patients with a low
instrumental activities of daily living score (hazard ratios per day of surgical delay 1.14, 95% confi dence interval 1.06 –
1.22, p < .001) and intermediate instrumental activities of daily living score (hazard ratios 1.21, 95% confi dence interval
1.09 – 1.34, p < .001) but was an insignifi cant risk factor in functionally independent patients (hazard ratios 1.05 95%
confi dence interval 0.79 – 1.41, p = .706).
Conclusions. Surgery delay is an independent factor for mortality in older patients after hip fracture but only for the
frail older people with prefracture functional impairment. If our results are confi rmed, a more intensive approach should
be adopted for older people with hip fractures who have disabilities.
Key Words: Hip fracture — Mortality — Functional status — Frail elderly — Surgery delay .
Received October 16 , 2011 ; Accepted February 25 , 2012
Decision Editor: Luigi Ferrucci, MD, PhD
PIOLI ET AL.
2
surgery delay and mortality in older people with HF ,
according to their level of functional impairment expressed
as the ability to autonomously carry out instrumental activities
of daily living (IADL).
M ethods
Participants and Data Collection
We performed a prospective multicenter cohort study of
consecutive patients, 75 years of age or older, admitted with
a fragility HF between March 2008 and February 2009 to
three hospitals of the Regional Health care System situated
in different districts of the Emilia-Romagna Region (Italy).
Patients whose fracture was due to secondary causes (bone
metastatic cancer, Paget ’ s disease of the bone) and who had
sustained a fracture due to a major trauma or a previous
fracture on the same hip were excluded. All three hospitals
had a comanaged care model, described in details elsewhere
( 11 ), and the patients were under the shared responsibility
of an orthopedic surgeon and a geriatrician. The study was
a part of a wider survey supported by the Emilia-Romagna
Regional Health Agency.
The geriatricians collected data on admission and during
in-hospital stay through a standardized comprehensive geri-
atric assessment. Information recorded on admission in-
cluded: age, gender, living arrangements (home, institution),
type and mechanism of fracture, functional and cognitive sta-
tus, comorbidity , and severity of illness. Prefracture func-
tional status (2 weeks before) was measured for basic
activities of daily living using the 6-item Katz Index ( 12 ) and
for IADL using the 8-item Lawton index ( 13 ). Each item was
logged as zero in case of total or partial assistance and as one
in case of complete independence. Moreover, walking ability
2 weeks before the trauma was assessed using a scale devel-
oped in the European Standardized Audit for fractured proxi-
mal femur ( 14 ). Cognitive status was assessed by the Short
Portable Mental Status Questionnaire (SPMSQ) (range 0 – 10
[ 15 ] ) . Thus, patients with a prior diagnosis of dementia or
with a n SPMSQ adjusted score of three or more errors were
classifi ed as having cognitive impairment. Medical burden
and comorbidity were measured using the Charlson index
( 16 ). Severity of illness on admission was measured by the
a cute p hysiology s core (score 0 – 71) of APACHE II ( 17 ).
Time to surgery (from admission), type of surgery , and length
of stay were collected from medical records. Time to surgery
usually ranged from 0 to 10 days. The very few cases with a
time to surgery longer than 10 days were all registered as 11
days for statistical purposes. Data on mortality up to 1 year
after fracture were gathered from the public registries includ-
ing Local Health Agency and Municipalities database.
Patients gave informed consent to participate in the study.
When the participants were too confused to understand the
informed consent process, proxy consent was obtained.
This study was approved by the Ethics Committee of the
Coordinating Center at the University Hospital Policlinico
S. Orsola Malpighi Bologna, and notifi cation was sent to
other local Ethics Committees.
Data Handling and Analyses
On the base of their IADL score, HF patients were catego-
rized into three subgroups according to their functional status.
Patients unable to perform independently all or almost all of
the items on the Lawton scale (IADL , score 0 – 2) were clas-
sifi ed as group 1, wh ereas patients who were independent in
all items or all but one (IADL , score 7 – 8) went into group 3
(high independence). The other patients (IADL , score 3 – 6)
were classifi ed as an intermediate level (group 2).
Categorical variables were expressed in percentages, and
continuous variables were reported as mean ± standard
deviation. One-way analysis of variance, Pearson ’ s χ
2 test , and
the Mann-Whitney U test were used to examine differences
in patients ’ baseline characteristics or crude data between
the groups.
The relationship between the IADL scale and mortality
was calculated by linear regression analyses. To determine
factors associated with 1-year mortality and the role of
surgical delays — treated as a continuous variable — a Cox
proportional hazards model was applied in order to control
for confounding. All variables found to be related to the sur-
vival time with the level of p value < .1 were included in the
multivariate analysis. To analyze the interaction between
functional status and time to surgery , a Cox regression
model was applied on the whole sample including the number
of IADL abilities lost (range 0 – 8), the delay to surgery in
days , and a derived variable from the product of the former
two variables. Regression was also adjusted for age, gender,
comorbidity, cognitive status , and acute physiology score.
Hazard r atios (HR) and 95% c onfi dence i ntervals (CIs)
were calculated. Signifi cance was set at p < .05. Statistical
analysis was performed with SPSS 18.0 for Windows (SPSS
Inc., Chicago, IL ).
R esults
Table 1 shows the baseline characteristics and outcomes
of the three functional status groups. As expected, given
that patients had been categorized according to functional
levels, all the baseline characteristics differed. Patients with
a higher comorbidity or with a severe illness at admission,
cognitive impairment, needing help to walk, and living in
institutions are more frequent in the lower functional
groups. Group 3 which included fully independent partici-
pants was also slightly but signifi cantly younger (mean age
83 y vs 87 and 86 in group 1 and 2 respectively, p < .001)
and with fewer male patients (20% vs 24 and 28 in group 1
and 2 respectively, p = .039). There is also an interesting
trend in the distribution of different fracture types: intracap-
sular fractures are more common in independent participants
and trochanteric fractures in disabled participants . As in
other studies ( 18 ) , patients with cervical fractures tend to be
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1274 PIOLI ET AL.
HIP FRACTURE IN FRAIL OLDER PEOPLE 3
slightly younger and healthier than those with trochanteric
fractures.
The differences between the groups in respect of length
of acute stay were very small, albeit statistically signifi cant.
Group 2 shows the highest mean in-hospital stay (13.5 d)
and group 3 the lowest (11.8 d, p = .003).
The IADL score was an important predictor of survival
after 1 year from fracture. Unadjusted HR per 1 point score
of increase from 0 to 8 in a logistic regression model was 1.34
(95% CI 1.26 – 1.43, p < .001) and 1.30 (95% CI 1.19 – 1.42,
p < .001) after controlling for age, gender, Charlson index ,
and cognitive impairment. A strong inverse relationship was
found between the mean 1-year survival rate and the IADL
score ( Figure 1 ) with R 2 = .83, p = .001.
Therefore, both 30-day mortality and 1-year mortality
showed marked and highly statistically signifi cant differences
among the three groups.
On the contrary, surgery delays showed no differences
among the three groups, probably because system factors
were more important than a patient’s characteristics in
determining the time of surgery. Figure 2 shows the distri-
bution of the whole sample of patients according to time to
surgery .
Predictors of 1-year mortality as derived by the multi-
variate Cox regression analysis in the three functional level
groups are shown in Table 2 . Among the basal characteris-
tics, comorbidity and severity at admission were signifi cant
independent factors in all three groups, wh ereas male gender
presented a signifi cant risk factor in groups 1 and 2, Katz
index only in group 1 , and age in group 2.
Time to surgery increased the 1-year mortality risk
by14% per day of surgical delay in group 1 (HR 1.16 95%
CI 1.09 – 1.23, p < .001) and by 21% in group 2 (HR 1.2 95%
CI 1.09 – 1.33, p < .001) but was an insignifi cant risk factor
in group 3. The results of interaction analysis performed on
the whole sample showed that time to surgery proved to be
a signifi cant risk factor (HR 1.16; 95% CI 1.02 – 1.33, p =
.028), as did the number of IADL abilities lost (HR 1.23;
Table 1. Baseline Characteristics of Patients and Outcomes by Functional Status Groups
Variables Group 1 (IADL 0 – 2) Group 2 (IADL 3 – 6) Group 3 (IADL 7 – 8) p Value All
No. 391 237 178 806
Age (mean ± SD ) 87.2 ± 5.4 85.5 ± 5.8 83.2 ± 5.3 <.001 85.8 ± 5.6
Sex (male %) 23.8 27.6 20.2 .039 23.7
Living in nursing home (%) 18.2 2.1 0 <.001 9.4
Fracture type (%) .055
Intracapsular 42.2 48.5 55.1 46.9
Trochanteric 51.2 42.6 37.6 46.0
Subtrochanteric 5.9 8.9 7.3 7.1
Charlson index (mean score ± SD ) 2.8 ± 2.1 2.2 ± 1.8 1.7 ± 1.7 <.001 2.4 ± 2.0
APS (mean score ± SD ) 3.4 ± 2.8 2.4 ± 2.4 2.2 ± 2.2 <.001 2.9 ± 2.6
Cognitive impairment (%) 91.9 48.5 28,1 <.001 62.2
Katz index (mean ± SD ) 2.6 ± 1.8* 5.2 ± 1.1 5.7 ± 0.5 <.001 4.1 ± 2.0
Independent walk (%) 44,5 89.0 97.2 <.001 69.2
Bed or wheelchair ridden (%) 7.4 0.8 0 <.001 4.0
Time to surgery (mean days ± SD ) 3.4 ± 2.1 3.3 ± 2.0 3.3 ± 1.8 .827 3.3 ± 2.0
Length of acute stay (mean days ± SD ) 12.2 ± 5.4 13.6 ± 6.9 11.8 ± 4.6 .003 12.5 ± 5.4.
30-d mortality (%) 9.7 5.9 1.7 .002 6.8
1-y mortality (%) 43.7 24.1 7.3 <.001 29.9
Note : IADL = Instrumental Activities of Daily Living; APS = Acute Physiology Score of APACHE II .
Figure 1. Distribution of the unadjusted survival rate of the patients after
1 year of follow-up according to Instrumental Activities of Daily Living (IADL)
score .
Figure 2. Distribution of the patients according to time to surgery.
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HIP FRACTURE IN FRAIL OLDER PEOPLE 1275
PIOLI ET AL.
4
95% CI 1.09 – 1.30, p = .001) but not the derived interaction
variable (HR .99; 95% CI 0 .98 – 1.02, p = .909).
D iscussion
The effect of time to surgery after HF on mortality has
been the focus of many investigations carried out over the
past two decades. Two recent meta-analyses ( 6 , 7 ) concluded
that surgery conducted within 48 hours is associated with
lower mortality as well as with lower rates of certain post-
operative complications. However , the evidence regarding
timing and outcome in HF surgery comes largely from
prospective or retrospective observational studies because
randomized controlled trials on this topic are not very
feasible or unethical ( 19 ). A larger review ( 8 ) of 52 pub-
lished studies found confl icting results regarding increased
mortality related to surgery delay , and the Authors empha-
size that more careful methodological studies are necessary
before defi nitive conclusions can be drawn and to establish
whether some patients may benefi t from early surgery more
than others.
The current study demonstrated that surgery delay is a
strong independent factor for mortality in older patients
after HF but only in the frail older people with prefracture
functional impairment. In prefracture fully independent
participants , surgery delays do not seem to increase 1-year
mortality.
Independence is usually measured in terms of functional
ability and we categorized patients using the IADL score to
capture the higher levels of abilities. Basic daily living
activities such as bathing, dressing, going to the toilet, trans-
ferring, continence , and eating are actually not indicative of
whether someone is able to live independently ( 20 ). On the
contrary, participants able to perform the majority of IADL
items without help certainly have a high level of indepen-
dence and can be considered fully independent. In our
cohort of unselected HF patients, 22% fall into this subgroup
(IADL score ≥ 7). The interaction analysis between the
IADL status and time to surgery proved not to be of any
statistical signifi cance. This result is not surprising because
our data do not reveal a linear increase in the negative effect
of delay to surgery in connection with the deterioration
of the functional status of patients. Our data only seem to
support the hypothesis that very healthy participants may suffer
fewer detrimental effects from surgery delay than impaired
participants , irrespective of the level of disability.
Prefracture functional status, along with other prefracture
individual characteristics such as comorbidity, advanced
age and male gender, is a well - established risk factor for
mortality after HF ( 2 , 3 , 21 – 23 ). Probably because of its
wide categorization in our study , the IADL score appeared
to have a very strong relationship with mortality and pro-
vided an effective means to categorize patients with signifi -
cantly different mortality risks. Looking at mortality risk
factors within the functional status groups, comorbidity and
severity at admission, as expected, were a signifi cant inde-
pendent risk factor in all three groups while delay to surgery
seemed to affect mortality only in impaired participants .
These results are in contrast with the conclusions drawn
by Shiga and colleagues ( 6 ) who found that delay to surgery
is harmful, especially for low risk or young patients. How-
ever, a more recent meta-analysis ( 7 ) found that delay to
surgery had a signifi cant infl uence on mortality after adjust-
ment for confounding preoperative factors regardless of
health status. The differences in study method (metaregres-
sion analysis vs subgroup analysis) as well as the reasons
for delays to surgery may explain the inconsistencies in the
results. In particular, the timing of surgery is often infl u-
enced by system factors such as the availability of an oper-
ating theater or medical or nursing staff , on the one hand, or
a patient ’ s preoperative medical condition, on the other,
such as the necessity to optimize a clinically unstable
patient or the need of further investigation ( 24 ). In most of
the studies included in Shiga ’ s meta-analysis, for a low
percentage of patients , intervention was postponed beyond
48 hours and this was mainly for medical reasons, whereas,
in the current study, 61% of participants underwent surgery
beyond 48 hours and the delays seemed to be prevalently
due to system factors. In fact, no differences in surgical
delays have been found between the functional groups and
no signifi cant correlations were established between delays
and comorbidity or severity at admission.
Table 2. Predictor of Mortality At 1 Y in the Three Groups of Patients According to Multivariate Cox Regression Model
Group 1 ( n = 391), (IADL 0 – 2) Group 2 ( n = 237), (IADL 3 – 6) Group 3 ( n = 178), (IADL 7 – 8)
Variables HR (95% CI) p Value HR (95% CI) p Value HR (95% CI) p Value
Age (per year of increase) 1.01 (0.97 – 1.04) .510 1.07 (1.02 – 1.13) .008 0.99 (0.86 – 1.15) .929
Gender (male vs female) 2.19 (1.48 – 3.24) <.001 2.69 (1.45 – 4.99) .002 2.70 (0.73 – 9.94) .136
Charlson index (per 1 score of increase) 1.08 (0.99 – 1.16) .056 1.24 (1.08 – 1.43) .003 1.35 (1.04 – 1.75) .024
Cognitive impairment (yes vs no) 1.18 (0.56 – 2.48) .663 0.93 (0.51 – 1.68) .808 1.57 (0.48 – 5.25) .459
Katz index (per 1 score of increase) 0.87 (0.78 – 0.96) .009 0.86 (0.63 – 1.18) .355 1.43 (0.32 – 6.32) .640
APS (per 1 score of increase) 1.11 (1.04 – 1.19) .003 1.11 (1.00 – 1.24) .051 1.47 (1.17 – 1.83) .001
Hospital (categorical) .462 .609 .801
Time to surgery (per 1 day of increase) 1.14 (1.06 – 1.22) <.001 1.21 (1.09 – 1.34) <.001 1.05 (0.79 – 1.41) .706
Note : IADL = Instrumental Activities of Daily Living; APS = Acute Physiology Score of APACHE II; HR = adjusted Hazard Ratio; CI = Confi dence Interval.
Hospital is a categorical variable reported only as total p value, since it is not signifi cant.
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1276 PIOLI ET AL.
HIP FRACTURE IN FRAIL OLDER PEOPLE 5
Currently , there are still confl icting opinions on which
patients should be considered medically fi t to undergo sur-
gery as soon as possible and which have conditions that
ought to be investigated and treated before surgery.
McLaughlin and colleagues ( 25 ) defi ned 11 classes of
preoperative clinical abnormalities (major and minor) that
were associated with poor postoperative outcomes in a
group of HF patients. They concluded that only major clin-
ical abnormalities should be corrected (if possible) prior to
surgery. Correction of major clinical abnormalities before
surgery improved the adjusted survival but postponement
without the correction of a medical abnormality before
surgery was associated with a signifi cantly lower adjusted
survival. Therefore , possible benefi ts of postponement need
to be weighed against prolonged discomfort for the patient
and the possibility of the development of other complications
( 26 ) such as pulmonary embolism, cardiac events, major
infection , and renal failure ( 27 ).
On the basis of our data , the harmful effects of prolonged
immobilization related to delays to surgery occur mainly in
the frail older people . These results are in agreement with
the concept expressed by Gill and colleagues ( 28 ), who
reported that the presence of physical frailty increased the
likelihood of developing new or worsening disability after
intervening illnesses and injuries. For example, the absolute
risk of transitioning from no disability to mild disability
within 1 month of hospitalization for frail individuals was
one of three and less than 5% for nonfrail individuals.
Our results have clinical implications because they sup-
port the concept that older people with HF and preexisting
disabilities need a more aggressive intervention than those
without disabilities. In particular, a quicker intervention and
a rapid optimization of clinical instability if present are
required. The timing of treatment for patients sustaining frac-
tures of the proximal femur is a big challenge for a health
care system. It requires both a coordination between several
disciplines and the availability of appropriate theater space
with trained staff ( 29 , 30 ). Important features of the new
care model include multidimensional evaluation that has
already been shown to improve outcomes in the frail older
people hospitalized in general hospital settings ( 31 ) and
collaboration between orthopedic and geriatric staff who
take action in the preoperative phase to optimize patients
before surgery at the same time avoiding nonessential inves-
tigation ( 29 , 32 ) in order to reduce delay to surgery.
The present study has several limitations. First of all, this
is only an observational study and although the analyses
were adjusted for confounding variables, the results must
be assessed with caution. At the same time, it should be
emphasized that randomized trials on time to surgery are
very diffi cult to carry out and unavoidably run the risk of
selection bias, usually by excluding just participants with
dementia or frailty ( 33 ). The real - world unselected samples
with a high rate of comorbid participant s are a strength of
this study.
A second limitation is the lack of data on the real reasons
for surgical delays. Only indirect data led to the attribution
of much of surgical delay to system factors. Therefore ,
other studies are needed to reinforce our results by focusing
on the effect of surgical delay in HF elderly subgroups with
different prefracture functional statuses or comorbidities.
However, if our results are confi rmed, the common practice
of operating fi rst on patients with no medical problems and
a high prefracture level of independence should change and
a more intensive approach should be adopted for the frail
HF older people .
F unding
This study was funded by Emilia-Romagna Region (University-Region
Research Program 2007 – 2009). The funder had no role in study design; or
in the collection, analysis, and interpretation of data; or in the writing of
the report or the decision to submit the article for publication.
Acknowledgment
We thank Paul Sears for his critical review of the English version of the
article and Silvio Cavuto for his statistical advice.
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